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Pharmacy staff say reporting errors to improve pharmacy practice and help others learn


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Last year, 95 per cent of the pharmacy staff have reported errors to improve pharmacy practice and 80 per cent to help others learn from mistakes, a recent study has found.

The survey conducted by the Community Pharmacy Patient Safety Group on patient safety culture in Autumn 2021 sought to understand patient safety practice from the perspective of frontline pharmacy teams.

According to the anonymous survey, the vast majority (91.4%) of respondents said the reporting procedure was “clear” or “very clear” and a similar proportion (91.6%) said they felt “fairly confident” or “completely confident” following reporting procedures correctly.

The study found that almost two thirds (65%) of respondents were aware of the change to the law, introduced in 2018, which provides a legal defence from criminal prosecution in the event of an inadvertent dispensing error. Of those who are aware of the change to the law, almost a third (29%) said they were more likely to report errors because of it.

Many respondents (59%) requested simpler reporting tools and a third (33%) indicated that training to support reporting would be beneficial. Over half of respondents said that they were either unfamiliar with the terminology “Just Culture” or didn’t know if their organisation followed the principles of it.

Victoria Steele, Chair of the Community Pharmacy Patient Safety Group said: “Community pharmacies deliver incredibly safe care. It will never be possible to eliminate all patient safety incidents in healthcare settings, including pharmacies, but reporting errors is essential if teams are to understand, investigate, learn from and ultimately prevent future incidents.

“We are really pleased to see high levels of confidence in reporting procedures and that teams are motivated to report errors in order to improve practice and share learnings. We note with interest that changes to the law have encouraged colleagues to report errors, however there is work to do to ensure all colleagues are aware of these changes.”

Steele added: “Whilst the results are promising, respondents also highlighted particular areas to support the reporting process including simpler reporting tools and increased training. We encourage contractors and policy makers to take this on board.

“In recent years, many within the pharmacy sector have also raised concerns about growing pressures on the community pharmacy workforce and its potential impact on patient safety. To enable colleagues to learn from errors, it is vital that pharmacy team members feel able to share when things go wrong, and businesses should instill a culture of openness and transparency to support this.”


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